Healthcare Provider Details

I. General information

NPI: 1558984005
Provider Name (Legal Business Name): BRILLIANTLY SANE COUNSELING AND COACHING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 06/13/2020
Certification Date: 06/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BRADLEY CT
BOULDER CO
80305-7310
US

IV. Provider business mailing address

PO BOX 1211
SILVERTHORNE CO
80498-1211
US

V. Phone/Fax

Practice location:
  • Phone: 970-368-9185
  • Fax:
Mailing address:
  • Phone: 970-389-3612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LISA WALLACE
Title or Position: OWNER
Credential: LPC
Phone: 970-368-9185